Totally laparoscopic transhiatal esophago-gastrectomy without thoracic or cervical access -: The least invasive surgery for adenocarcinoma of the cardia?

Background: The recent progress of minimally invasive surgery has allowed esophagectomy to be performed by both combined laparoscopic/thoracoscopic and totally laparoscopic transhiatal approaches. All these techniques imply a thoracic and/or cervical access for the creation of the esophagogastric anastomosis. Methods: Five surgical ports are introduced in the abdomen. The stomach is mobilized, divided, and tubulized, preserving the right arteries. The lymphadenectomy of the celiac trunk and the hepatic pedicle is achieved. The dissection and resection of distal esophagus and a two-fields mediastinal lymphadenectomy are performed by means of harmonic scalpel. The realization of the intrathoracic esophago-gastrostomy is accomplished by means of a circular stapler. Results: Three patients underwent the procedure. Mean operating time and blood loss were 347 min and 360 cc. There were no intraoperative or postoperative complications. Mean postoperative stay was 9 days. Conclusion: In selected cases, it is possible to perform a distal esophagectomy entirely by laparoscopy, without the need for any thoracic or cervical access.